2012_0810 (4)CHECK ONE:
IRRIGATION
DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF COPPELL
LOCATION OF SERVICE:
The bad -Low prevention assembly detailed below has been tested and maintained as required by TNRCC
re-sWwons and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle a Pressure Vacuum Breaker
1Z' Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number 047 kv,1 Located At oil S `'d
Serial Number .SBSS z
The above is testified to be true.
Firm Name tQ -e
Firm Address PO B n ? °l LA4
Gauge # O 7 0 g o L- e
Date last accuracy tested 7-,3 l - 1 z-
Certified Testa APIA''-fk 6v.2111
Cent, Tester No. Pv+w &15 7 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Rye{ Valve
Air Inlet
Check Valve
1st Check 2 , q-
2nd Check Z -°
Initial Test
DC- Closed
Tight
Closed Tight
Leaked ❑
Opened at
vsid
Opened at
�osid
--esid
RP- __.psid
Leaked ❑
Did not Open ❑
Leaked o
Repairs
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight E3
Opened at
sid
Opened at
osid
__sid
M====a sid
The above is testified to be true.
Firm Name tQ -e
Firm Address PO B n ? °l LA4
Gauge # O 7 0 g o L- e
Date last accuracy tested 7-,3 l - 1 z-
Certified Testa APIA''-fk 6v.2111
Cent, Tester No. Pv+w &15 7 Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy